56 year old male with urinary tract infection

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DEC 2nd,2021

56 YEAR OLD MALE WITH URINARY TRACT INFECTION

CASE DISCUSSION:-

A 56 year old male ,presented to the OPD on 1st December with chief complaints ofChief complaints of

 ->High grade fever since 3 days

 -> Burning micturation since 3 days

 ->Lower back pain since 3 days

HISTORY OF PRESENT ILLNESS:-

 ->4 yrs ago Pt. had fever. Fever was low garde ,associated with chills . 

->Burning micturition since 4 years,which is on and off.Burning is present only during voiding.

 ->4 years ago he was admitted in our hospital and diagnosed with Diabetes mellitus and he underwent dialysis once.

->he is on medication for DM since 2 yrs (H.Actrapid )

-High grade fever with chill since 3 days  associated with burning micturition

- Decreased urine output since 3 days 

- History of vomiting - food as content and billious vomiting since 2 days 

- SOB since 3 days 

- lower back pain since 3 days 

- no complqin of cough , loose stools ,            rashes , body pain , pedal edema 

HISTORY OF PAST ILLNESS :-

- known case of DM since 4 years , on      injection Human ACTRAPID since 2 years 

-was informed to have kidney disease,not on any medication.

- not a known case of HTN , CAD 

PERSONAL HISTORY :-

Diet : Veg 

Appetite : normal 

Bowel movement regular 

Burning micturition 

Occassional alcoholic 

Sleep disturbed 

GENERAL EXAMINATION:-

Patient was examined in well lit room with his consent .

Patient is conscious ,coherent and cooperative 

Patient is well oriented to time and place

Moderately built and nourished

INVESTIGATIONS:-

Pallor:absent

Icterus: absent

Clubbing:absent

Cyanosis:absent

Lymphadenopathy: absent

Edema: absent

VITALS:-

Temperature: 99.3 F

Pulse: 92 / min

Respiratory rate : 25 bpm

Blood pressure : 120/80 mmHg

SpO2 at room air : 98 per cent 

GRBS : 180 mg/dL

SYSTEMIC EXAMINATION :-

Cardiovascular system

-s1 and s2 heard ,no murmurs 

Respiratory system

-Central position of trachea 

-Vesicular breath sounds

-No wheeze,no dyspnea

Abdominal examination

-Scaphoid shape

-No tenderness

-No palpable masses

 -bowel sounds heard 

-No organomegaly

CNS Examination 

-No FND 

PROVISIONAL DIAGNOSIS:-

1)UTI

2)AKI on ?CKD

3) Thrombocytopenia

INVESTIGATIONS:-

On 2/12/2021:-

PH-7.34

PCO2-24.4mmHg

PO2-74.8mmHg

SO2-94.3%

RBS-99mg/dl

HCO3-13.1mEq/L

Dengue-negative

RT-PCR-negative

CUE:-

Pus cells- 3 to 4

Epithelial cells-2 to 3

RBC-nil

FBS-89mg/dl

PLBS-108mg/l

Hb- 14.4 mg/dl

TLC- 7390

PLT- 55,000

BGT- O Positive

Serum Urea- 94

Serum Creatinine- 3.1

Serum Uric Acid- 7.1

Na- 141

K- 4.2

Cl- 102

Total Bilirubin- 4.41

Direct Bilirubin- 2.24

AST- 52

ALT- 22

ALP- 103

TP- 5.5

ALB- 3.3

A/G- 1.61

PT-16

APTT-31

TREATMENT:-

1)IVF- 2NS, 2RS @75ml/hr

2)Inj.Pantop 40 mg IV OD

3)Inj.Zofer 4 mg IV BD

4)syp.Citralka 10 ml in 1 glass of water PO BD

5)GRBS- 6th hourly(8am-2pm-8pm-2am)

6)Inj.Human Antrapid SC TID

7)BP,HR,SPO2 charting

8)Tab.Dolo 650 mg PO TID

9)Inj.Neomol 1 gm IV (if temp >101F)

10) Temperature charting 4th hourly

11)Plenty of oral fuids

12)Strict I/O charting

13)Inj.Ciprofloxacin 200 mg IV BD

14) Syp.Aristrozyme 10 ml PO BD

15)Syp.Sucralfate 10 ml PO BD